Custom Hospice, LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review and interview. In 6 of 23 (26%) records reviewed it was revealed that the agency did not ensure that the drug profile contained the patient’s current drugs. Document 6: Policy No. 4-050.1 titled Medication Profile read in part, “1. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, 2. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” Clinical Record 5: The licensed practical nurse visit note, and the associated physician order dated 01/28/2024 read in part, “Cipro 500 mg bid x 5days.” At the time of the review on 02/14/2024 Cipro was not included on the medication profile. Clinical Record 6: The plan of care dated 12/21/2023 read in part, “Oxygen @ 2-4 LPM via nasal cannula.” At the time of the review on 02/14/2024 oxygen was not included on the medication profile. Clinical Record 8: The medication profile read in part, “’11/30/2023 Amoxicillin 500mg 1 tab by mouth twice daily for 7 days.” At the time of the review on 02/14/2024, Amoxicillin was still listed as an active medication. Clinical Record 9: The hospice plan of care dated 01/31/2024 read in part, “Oxygen @ 5 LPM via nasal cannula.” At the time of the review on 02/14/2024 oxygen was not included on the medication profile. Clinical Record 15: The medication profile read in part, “02/05/2024 Cipro 500mg 1 tab by mouth twice daily for 5 days.” At the time of the review on 02/15/2024, Cipro was still listed as an active medication. Clinical Record 19: The plan of care dated 12/15/2023 read in part, “Oxygen @ 2-4 LPM via nasal cannula.” At the time of the review on 02/15/2024 oxygen was not included on the medication profile. During interview on 02/16/2024, the Alternate DPCS reviewed the associated records and stated the medication profile errors had since been corrected.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 23 (22%) records reviewed it was revealed that the agency did not ensure each patient’s individualized written plan of care included all treatment necessary to meet the needs of the patient. Document 5: Policy No. 4-027.1 The Plan of Care read in part, “The plan of care will focus on identified problems, goals and interventions. 12. The written plan of care will contain but will not be limited to the following: T. Drugs and treatments.” Clinical Record 6: The comprehensive assessment dated 12/21/2023 included documentation that the patient had a nasogastric tube, foley catheter and a stage IV wound to left lower extremity. At the time of the review on 02/14/2024 the initial plan of care dated 12/21/2023, and the updated plans of care dated 01/03/2024, 01/17/2024 and the 01/31/2024 did not include orders related to the care/management of the nasogastric tube, foley catheter or the wound. Clinical Record 12: The comprehensive assessment date 01/26/2024 included documentation that the patient had a foley catheter. At the time of the review on 02/15/2024 the initial plan of care dated 01/26/2024 and the updated plan of care dated 02/07/2024 did not include orders related to the care/management of the foley catheter. Clinical Record 13: The comprehensive assessment dated 01/11/2024 included documentation that the patient had a diagnosis of insulin dependent Diabetes. At the time of the review on 02/15/2024 the initial plan of care dated 01/11/2024 and the updated hospice plans of care did not include orders related to the care/management of the Diabetes. Clinical Record 21: The comprehensive assessment dated 01/15/2024 included documentation that the patient had a condom catheter. At the time of the review on 02/15/2024 the initial plan of care dated 01/15/2024 and the updated plans of care dated 01/24/2024 and 02/07/2024 did not include orders related to the care/management of the condom catheter. Clinical Record 22: The comprehensive assessment dated 11/16/2023 included documentation that the patient had a foley catheter. At the time of the review on 02/15/2024 the initial plan of care dated 11/16/2023 and the updated plans of care dated 11/22/2023, 12/06/2023, 12/20/2023 and the 01/03/2024, did not include orders related to the care/management of the foley catheter. During interview on 02/26/2024, the Alternate DPCS reviewed the associated records and stated that the hospice plans of care had since been corrected.”

“It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 23 (22%) records reviewed the agency did not ensure that care and services provided are in accordance with the plan of care. Clinical Record 1: The hospice election of benefit form was dated 09/30/2023. The hospice plan of care for the benefit period dated 12/29/2023 read in part, “SN 2xweek.” At the time of the review on 02/13/2024 there were no documented nursing visits for the week of 12/29/2023 and no documented explanation of why care was not provided at the ordered frequency. Clinical Record 5: The hospice election of benefit form was dated 02/01/2023. The hospice plan of care for the benefit period dated 01/27/2024 read in part, “SN 2xweek.” At the time of the review on 02/14/2024 there were no documented nursing visits for the week of 01/27/2024 and no documented explanation of why care was not provided at the frequency ordered. Clinical Record 9: The hospice election of benefit form was dated 01/06/2023. The hospice plan of care for the benefit period dated 01/31/2024 read in part, “SN 2xweek.” At the time of the review on 02/14/2024 there was only one documented nursing visit for the week of 01/31/2024 dated 02/01/2024 and no documented explanation of why care was not provided at the ordered frequency. Clinical Record 12: The hospice election of benefit form was dated 01/16/2024. The hospice plan of care for the benefit period dated 01/16/2024 read in part, “SN 2xweek.” The physician’s order dated 01/31/2024 read, “SN 3xweek.” At the time of the review on 02/15/2024 there were only two documented nursing visits for the week of 01/31/2024 dated 01/31/2024 and 02/02/2024 and no documented explanation of why care was not provided at the ordered frequency. Clinical Record 19: The hospice election of benefit form was dated 12/15/2023. The hospice plan of care for the benefit period dated 12/15/2023 read in part, “SN 3xweek.” At the time of the review on 02/15/2024 there were only two documented nursing visits for the week of 12/15/2023 dated 12/15/2023 and 12/16/2023 and no documented explanation of why care was not provided at the frequency ordered. During interview on 02/16/2024, the Alternate PCS reviewed the associated records and stated that the missed visit entries and visit frequencies had since been addressed.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 17 (24%) records reviewed of patients that were provided with aide services, it was revealed that the agency did not ensure that the written patient care instructions were individualized. Document 7: Policy No. 4-0061 Home Health Aide Plan of Care read in part, “1. The patient’s case manager upon initiation of aide services will develop a written home health aide plan of care, consistent with the comprehensive plan of care and physician orders. 2.The home health aide plan of care will be individualized to the specific patient and will include at least: D. functional limitation F. Activities permitted I. safety measures 7. The Case Manager or other appropriate clinician will supervise the home health aide at least every 14 days to ensure care is provided according to plan.” Clinical Record 6: The comprehensive assessment dated 12/21/2023 documented the patient utilized oxygen, a nasogastric tube for feeding and had a stage IV pressure wound to the left lower extremity. There was no guidance noted on the hospice aide care plan created 12/21/2023 by the registered nurse, at the time of the review on 02/14/2024. Clinical Record 12: The updated assessment note date 02/12/2024 included the identification of a new wound and physician’s orders for wound care. At the time of the review on 02/15/2024, the aide care plan had not been updated with guidance related to the new wound. An aide visit was documented on 02/13/2024. Clinical Record 13: The hospice aide care plan created 01/11/2024 included foley catheter care every visit. The updated comprehensive assessment dated 01/12/2024 read in part, “Foley catheter discontinued.” At the time of the review on 02/15/2024, the hospice aide care plan had not been updated. Clinical Record 20: The comprehensive assessment dated 01/26/2024 read in part, “Unstageable pressure ulcer to coccyx, deep tissue injury to left heel, and blister to left calf.” Each had associated wound care orders. At the time of the review on 02/15/2024, the 01/26/2024 hospice aide care plan did not include guidance related to wounds. During interview on 02/16/2024, the Alternate DPCS reviewed the associated records and stated that the care plan instructions had since been corrected and remedial education to staff would be provided.”

“It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 9 of 17 (53%) records reviewed of patients that received aide services, it was revealed that the agency did not ensure services were provided as per the plan of care. Document 7: Policy No. 4-0061 Home Health Aide Plan of Care read in part, “1. The patient’s case manager upon initiation of aide services will develop a written home health aide plan of care, consistent with the comprehensive plan of care and physician orders. 2.The home health aide plan of care will be individualized to the specific patient and will include at least: D. functional limitation F. Activities permitted I. safety measures 7. The Case Manager or other appropriate clinician will supervise the home health aide at least every 14 days to ensure care is provided according to plan.” Clinical Record 1: The hospice election of benefit form was dated 09/30/2023. The hospice plan of care for the benefit period dated 12/29/2023 included an aide visit frequency of 2xweek. At the time of the review on 02/13/2024, there were no aide visits documented for the week of 12/29/2023 and no documented explanation of why services were not provided as ordered. Clinical Record 2: The hospice plan of care dated 12/22/2023 included an aide visit frequency of 2xweek. At the time of the review on 02/13/2024, there were no aide visits documented for the week of 12/23/2023 and no documented explanation of why services were not provided as ordered. Clinical Record 3: The hospice plan of care dated 12/13/2023 included an aide visit frequency of 2xweek. At the time of the review on 02/13/2024, there was only one aide visit documented on 12/14/2023 for the week of 12/23/2023 and no documented explanation of why services were not provided as ordered. Clinical Record 4: The hospice plan of care dated 12/07/2023 included an aide visit frequency of 2xweek. At the time of the review on 02/14/2024, there was only one aide visit documented on 12/08/2023 for the week of 12/07/2023 and no documented explanation of why services were not provided as ordered. Clinical Record 5: The hospice election of benefit form was dated 02/01/2023. The hospice plan of care dated 01/27/2024 included an aide visit frequency of 2xweek. At the time of the review on 02/14/2024, there were no aide visits documented for the week of 01/27/2024 and no documented explanation of why services were not provided as ordered. Clinical Record 9: The hospice election of benefit form was dated 01/06/2023. The hospice plan of care for the benefit period dated 01/31/2024 included an aide visit frequency of 2xweek. At the time of the review on 02/14/2024, there was only one aide visit documented for the week of 01/31/2024 and no documented explanation of why services were not provided as ordered. Clinical Record 11: The hospice election of benefit form was dated 09/21/2023. The hospice plan of care for the benefit period dated 12/20/2023 included an aide visit frequency of 2xweek. At the time of the review on 02/14/2024, there was only one aide visit documented for the week of 12/20/2023 and no documented explanation of why services were not provided as ordered. Clinical Record 12: The hospice aide plan of care dated 01/16/2024 included a task frequency of weekly for nail care. At the time of the review on 02/15/2024, the aide visit note documentation for the week of 01/30/2024 dated 01/30/2024 and 02/10/2024, included completion of nail care at each visit instead of at the weekly frequency ordered. Clinical Record 23: The hospice plan of care dated 12/15/2023 included an aide visit frequency of 2xweek. At the time of the review on 02/15/2024, there were no aide visits documented for the week of 12/15/2023 and no documented explanation of why services were not provided as ordered. During interview on 02/16/2024, the Alternate DPCS reviewed the associated records and stated the frequencies and/or the required missed visit entries had since been addressed.”

“It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 13 of 23 (57%) records reviewed the agency did ensure all entries were appropriately authenticated and dated. Clinical Record 1: The hospice election of benefit form was dated 09/30/2023. Upon review of the 12/29/2023 hospice benefit period on 02/13/2024, the 01/18/2024, 01/24/2024 and the 02/13/2024 chaplain visit notes did not include credentials with the associated signature and date. Clinical Record 2: The hospice election of benefit form was dated 12/23/2023. Upon review of the 12/23/2023 hospice benefit period on 02/13/2024, the 12/27/2023, 01/08/2024 and the 01/25/2024 chaplain visit notes did not include credentials with the associated signature and date. Clinical Record 4: The hospice election of benefit form was dated 12/07/2023. Upon review of the 12/07/2023 hospice benefit period on 02/14/2024, the 01/03/2024 and the 01/08-02/05/2024 aide visit notes did not include credentials with the associated signature and date. Clinical Record 11: The hospice election of benefit form was dated 09/21/2023. Upon review of the 12/20/2023 hospice benefit period on 02/15/2024, the visit note completed 01/07/2024 by the licensed practical nurse did not have a date with the associated signature and credentials. Clinical Record 12: The hospice election of benefit form was dated 01/16/2024. Upon review of the 01/16/2024 hospice benefit period on 02/15/2024, the communication note completed 01/25/2024 by licensed practical nurse did not have credentials with the associated signature and date. Clinical Record 14: The hospice election of benefit form was dated 01/16/2024. Upon review of the 01/16/2024 hospice benefit period on 02/15/2024, the communication note dated 01/16/2024 by the social worker and the communication note dated 01/17/2024 by the chaplain did not include credentials with the associated signatures and dates. Clinical Record 15: The hospice election of benefit form was dated 01/03/2024. Upon review of the 01/03/2024 hospice benefit period on 02/15/2024, the visit note dated 01/04/2024 by the chaplain did not have credentials with the associated signature and date. Clinical Record 16: The hospice election of benefit form was dated 01/20/2024. Upon review of the 01/20/2024 hospice benefit period on 02/15/2024, the visit note dated 01/23/2024 by the chaplain did not have credentials with the associated signature and date. Clinical Record 18: The hospice election of benefit form was dated 01/19/2024. Upon review of the 01/19/2024 hospice benefit period on 02/15/2024, the visit note dated 01/31/2024 by the chaplain note did not include credentials with the associated signature and date. Clinical Record 19: The hospice election of benefit form was dated 12/15/2023. Upon review of the 01/10/2024 hospice bereavement plan of care on 02/15/2024, the notes dated 01/16/2024 and the 01/24/2024 by the bereavement coordinator did not have credentials with the associated signatures and dates. Clinical Record 20: The hospice election of benefit form was dated 01/26/2024. Upon review of the 02/03/2024 hospice bereavement plan of care on 02/15/2024, the notes dated 02/06/2024 and the 02/08/2024 by the bereavement coordinator did not have credentials with the associated signatures and dates. Clinical Record 21: The hospice election of benefit form was dated 01/15/2024. Upon review of the 02/05/2024 hospice bereavement plan of care on 02/15/2024, the notes dated 02/06/2024, 02/09/2024/2024 and 02/12/2024 by the bereavement coordinator did not have credentials with the associated signatures and dates. Clinical Record 23: The hospice election of benefit form was dated 12/15/2023. Upon review of the 12/15/2023 hospice benefit period on 02/15/2024, the visit notes dated 12/18/2023 and the 12/26/2023 by the chaplain did not have credentials with the associated signatures and dates. During an interview on 02/16/2024, the Alternate DPCS reviewed the associated records and stated the missing dates and credentials had since been corrected.”

“It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by clinical record review, document review and interview. In 23 of 23 (100%) records reviewed it was revealed that the agency did not ensure a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Document 2: Policy No. 4-054.1 Home Use and Disposal of Controlled Substances read in part, “2. The Admitting Nurse/Case Manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family. The Admitting Nurse/Case Manager will document in the clinical record that the patient/representative and family have received a copy of the policies and procedures.” Clinical Record 1: The hospice election of benefit form was dated 09/30/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 2: The hospice election of benefit form was dated 12/23/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 3: The hospice election of benefit form was dated 12/13/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 4: The hospice election of benefit form was dated 12/07/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 5: The hospice election of benefit form was dated 02/01/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 6: The hospice election of benefit form was dated 12/21/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 7: The hospice election of benefit form was dated 09/29/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 8: The hospice election of benefit form was dated 11/20/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 9: The hospice election of benefit form was dated 01/06/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 10: The hospice election of benefit form was dated 10/12/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 11: The hospice election of benefit form was dated 09/21/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 12: The hospice election of benefit form was dated 01/16/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 13: The hospice election of benefit form was dated 01/11/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 14: The hospice election of benefit form was dated 01/16/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 15: The hospice election of benefit form was dated 01/03/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 16: The hospice election of benefit form was dated 01/20/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 17: The hospice election of benefit form was dated 08/25/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 18: The hospice election of benefit form was dated 01/19/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 19: The hospice election of benefit form was dated 12/15/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 20: The hospice election of benefit form was dated 01/26/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 21: The hospice election of benefit form was dated 01/15/2024. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 22: The hospice election of benefit form was dated 11/16/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). Clinical Record 23: The hospice election of benefit form was dated 12/15/2023. At the time of the review on 02/13/2024, there was no evidence that the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family or patient’s legal representative(s). During interview on 02/16/2024, the Alternate DPCS reviewed the associated records and admission packet and stated that the agency had not been providing the policy nor documenting as such.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) records reviewed of patients that resided in a SNF, it was revealed that the agency did not ensure the hospice plan of care included identification of which provider was responsible for performing the agreed upon functions. Clinical Record 20: The 01/26/2024 comprehensive assessment stated patient was a resident of a skilled nursing facility. The 01/26/204 hospice plan of care read in part, “Cleanse unstageable pressure ulcer to coccyx with wound cleanser, pat dry, apply skin barrier with foam dressing. Change daily and as needed for soling/dislodgement. DTI left heel, cleanse with wound cleanser, pat dry, apply skin prep tid. Left medial calf blister- cleanse with wound cleanser, pat dry, apply crushed Flagyl to wound bed, apply xeroform and wrap with Kerlix, secure with tape. Change twice daily and as needed for soiling/dislodgement.” At the time of the review on 02/15/2024 the plan of care did not specify which provider was responsible for the wound care. During interview on 02/16/2024, the Alternate DPCS reviewed the associated record and stated the nursing notes referenced the facility staff was performing care however the hospice plan of care did not specify which provider was to perform the wound care.”